A Young Practitioners guide to record keeping

A Young Practitioner's guide to record keeping

Here’s everything you need to know about effective record keeping as you’re practising dentistry.

Survival Guide Introduction

Read this article to:

Refresh your knowledge of best practice for record keeping

Learn ways to avoid confusion in your notes

Find links to guidance and further online advice

Dental records are one of the more vexing issues we deal with. We all appreciate their importance in the provision of excellent patient care, to verify the discussions that we had with the patient and evidence that we had their full and valid consent to proceed. However, time pressures can lead to this critical element of practice being neglected.

Recent graduates often contact Dental Protection with reports they’ve been chastised for “taking too long” to write their records or “writing too much”. Unfortunately this criticism can lead graduates to be tempted to cut corners, perhaps bow to the pressure they are under or mimic the more senior practitioners and not keep as comprehensive records as they should. Bad habits can form and the records one has to defend themselves with, when it really matters, may be far inferior to the records one would have made, had they been given the time, opportunity and space to write what they intended.

So what’s the standard?

On 1st October 2020 the Dental Board of Australia removed their guidance for dental records document, and replaced with the Code of Conduct. Multiple sections of the Code deal with records, however Section 8.4 is dedicated to dental records. This change is part of the drive by the Dental Board to place the responsibly for creating records, and also reviewing whether they are fit for purpose onto the dental practitioner. They have also created a self-reflective tool to assist in this review and a fact sheet to support this. While this may seem clear cut, the documents are not prescriptive in many areas, which may lead to practitioners inadvertently leaving themselves exposed.

Risks and warnings

Those with sharp eyes will note that the guidance does not state that risks and warnings about treatment modalities must be given. These are, however, implicit within ‘consent of the patient’ and experience tells us that failing to document each individual risk and warning leaves a practitioner vulnerable when they come to defending themselves – as all too often a patient will state: “they never told me, and had I known I would never have proceeded with the treatment.”

In the absence of clinical records that document what the patient was told, that patient will then be believed when they say they were not. Without knowing what can go wrong with a treatment (as well as what can go right) and without fully understanding the alternative treatment options available (including the option of no treatment) a patient cannot truly have given consent to treatment and, without consent, treatment is viewed as battery.

Is simply writing ‘risks and warnings given’ enough?

No. Each risk given must be detailed in the records.

For example, the risks and warnings given prior to the extraction of a lower wisdom tooth whilst obtaining consent could read:

Patient advised tooth could be left, however it will continue to become infected and cause pain. Tooth heavily decayed and abscessed, recommended extraction as hopeless prognosis. Patient advised re: bleed/pain/swell/bruise/trismus/paraesthesia – which may be permanent/may be unable to fully extract tooth requiring specialist referral/roots may persist/may require surgical +/- bone removal +/- stiches/no smoking. Offered referral to specialist.

Whereas the records relating to the extraction of an upper wisdom tooth in the same circumstances will contain some similarities, but also some marked differences:

Patient advised tooth could be left, however it will continue to become infected and cause pain. Tooth heavily decayed and abscessed, recommended extraction as hopeless prognosis. Patient advised re: bleed/pain/swell/bruise/extract tooth requiring specialist referral/roots may persist/may require surgical +/- bone removal +/- stiches/root may be displaced into sinus requiring further treatment with a specialist/creation of OAF which may need further treatment/care nose blow/no smoking. Offered referral to specialist.

Quick notes can be an incredibly helpful aid to rapidly document extensive notes; however, it is important that these are personalised for each patient, and not a button to be tapped in the place of writing comprehensive records. Many a practitioner has looked foolish in front of the dental board when they have confidently stated that their records verify the patient understood the risks and warnings, only to be embarrassed by the inclusion of risks unrelated to the procedure they undertook contained within those records. Failure to personalise quick notes proves only that you can press a button, not that you had valid consent.

Shortcuts and time savers

There are some simple ways of ensuring that you make comprehensive records, but still leaving you with ample time to treat your patients!

Quick notes

While they have limitations, and should be personalised, there can be no doubt of their value, particularly when used to appropriately auto-populate medicaments and materials used in everyday dentistry.

DA records

It is permissible for your dental assistant (DA) to write your records; however, as the registrant, you have the responsibility of checking the records and verifying their accuracy. All parties who contribute to the records must sign the records.

Digital dictation

We are not quite at the stage where a .wav file is accepted as a clinical record but you can consider dictating your records into your phone and then typing them at the end of the day (or getting your trusty front office staff to do so for you). Again, if the records are typed by someone else, then they also need to be checked and signed by you.

Abbreviations

It is accepted to use commonplace abbreviations in your clinical notes. Some good sources of these include utilising those recognised by the World Health organisation, and considering sources such as that set out below:

http://www.medwords.com.au/Medwords/MW_S_Students_files/ABBREVIATIONS.pdf

Nevertheless, care needs to be taken as the meaning of many abbreviations has changed over time, or can be open to different interpretation dependent on your setting. An example is:

AOB

Used in the description of orthodontics to signify an ‘anterior open bite’ this abbreviation is oft seen in hospitals to identify that the patient had ‘alcohol on breath’; it is easy to see how a misinterpretation of this may lead to an entirely different outcome if there is an adverse outcome or patient complaint.

Bringing it all together

Careful, concise and contemporaneous notes are the only way to ensure appropriate patient care, and enable a practitioner to defend themselves if challenged about the nature and type of treatment they provided, and the discussions which preceded it. Shortcuts can be a valuable time saver, but utilise with care to ensure they are beneficial rather than prejudicial.